1. COMPONENTS OF THE MEDICAL HISTORY Jim Winger, M.D.
Components of Medical History Lecture
Patient Centered Medicine 1
COMPONENTS OF THE MEDICAL HISTORY Jim Winger, M.D.

2. Objectives Define the components of the medical history
Describe open and closed ended questioning and when to utilize each
Define the patient’s perspective of illness

3. COMPONENTS OF THE MEDICAL HISTORY
Components of Medical History Lecture
COMPONENTS OF THE MEDICAL HISTORY
Identifying Data (ID)
Chief Complaint (CC)
History of Present Illness (HPI)
Medical History
Surgical History
Therapies
Allergies
Psycho Social History (PSH)
Family History (FH)
Review of Systems (ROS)

4. Identifying Data (ID) Name or initials Date of birth
Medical record number

5. Chief Concern (CC)
One-liner--why patient here--use patient's own words
How to write--patient’s age, occupation or sex, problem & duration
“UM is a 52 year old male lawyer/folk singer with one week of ‘pain in my chest’”

6. History of Present Illness (HPI) the biomedical perspective
Story(-ies) of patient’s chief concern (CC)
If separate issues, treat differently with clearly defined documentation
Story of any active/significant illnesses patient has which impact HPI
If CC is chest pain:
Smoking
Cholesterol history
Family history of CAD

7. History of Present Illness (HPI)
Story of CC:
logical
complete
chronological

8. History of Present Illness (HPI)
Story of CC (How To Ask):
start with open-ended questions
At least three!
‘tell me what brings you in today’
‘tell me more…’
‘what else’
fill in with focused questions
Can you tell me if this pain has any relationship to eating?

9. History of Present Illness (HPI)
Cardinal Characteristics of a Symptom:
(very closed questions)
Describe symptoms in terms of:
location
quality
quantity (severity)
timing
setting
aggravating and/or alleviating factors
associated manifestations

10. History of Present Illness (HPI)
Story of CC
Putting appropriate information into HPI
prior medical Dx/Rx
significant positives or negatives

11. History of Present Illness (HPI)
Patient’s Perspective of Illness:
Document patient’s understanding of his/her illness:
patient’s fears and concerns
impact of illness/treatment on patient, family

12. History of Present Illness (HPI)
Story of CC
logical, complete, chronological
open-to-closed questioning
characterize symptoms
document:
prior medical diagnoses/treatments
significant positives/negatives
patient's understanding of illness
Story of any active/significant illnesses patient has which impact on HPI

13. Components of Medical History Lecture
Adult illnesses
Injuries/accidents
Health Screening Examinations
Immunizations
Childhood illnesses
Obstetric history
Psychiatric illnesses or Hospitalizations

14. Adult Illnesses
Diagnosis & how made
Treatment
Response & sequelae

15. Obstetric & Gynecologic History
Number times pregnant
Number live births
Number abortions (spontaneous/induced)
Fertility concerns
History of STIs
Abnormal cervical cancer screening

16. Therapies and Allergies
Components of Medical History Lecture
Therapies and Allergies
Current medications--name, dose, reason, side effects; including OTC
Furosemide 20mg one by mouth daily
Allergies/drug reactions
Lisinopril (cough)
Complimentary & Alternative Therapies
Accupuncture, chiropractic, herbs, supplements
What allergen, what reaction
Differentiate side effects from drug reactions
Morphine (drowsiness)
Amoxicillin (hives)

17. Psycho-Social History (PSH)
Marital & Relationship status/satisfaction
Living conditions and home safety
Employment (exposures/risks/satisfaction)
Military service
Sexual history
Significant life events and stressors
Diet/sleep/exercise
Alcohol/Tobacco/Drugs
How much/how long/type/quit date & method

18. Surgical History Operations Why, Diagnoses Kind When & sequelae
Anesthesia hx

19. Family History (FH) Mother/father/siblings/children
age--health (if dead, why)
Significant illnesses that run in family
May consider genogram

20. Review of Systems (ROS)
Characterize patient's overall health status
Review systems/symptoms from head to toe